Improving health outcomes, through better communication and engagement with patients, is a cornerstone of practice in the Military Health System. MHS GENESIS, the Department of Defense's new electronic health record, is helping standardize care delivery of this best practice, specifically through its patient portal. The portal includes the first MHS implementation of the concept of open notes, which enables patients to access the notes providers write to document each clinical encounter.

Open notes offer many evidence-based advantages through mutual communication, understanding, and collaboration. Even so, some providers are a bit cautious about the approach. These clinicians worry that patients might misinterpret or disagree with the note contents, potentially leading to interpersonal friction or adverse clinical outcomes.

Undoubtedly, encouraging patients to explore their providers' perspective on clinical interactions fundamentally changes their relationship with providers. Adapting to open notes is easier than you may think, however, and helps providers meet patients where they are and build stronger, more trusted relationships. Open notes enables two-way communication and feedback that encourages providers and patients to feel that they are not just on the same page, but in the same boat on a shared journey.

Flipping the Script

Traditionally, providers have written their session notes to communicate solely with other providers. Patients might get a copy of their record but they rarely if ever read it, often because their providers don't encourage them to and they have to wade through dense jargon if they do. Open notes flips that script by giving patients on-demand access to their providers' observations and instructions and encourages clear dialogue about that content.

As providers, we can encourage patients to take advantage of open notes in each session by asking, "Did you read the note from the last appointment? If so, was there anything that wasn't clear or that you have questions about?"

The patient can read the note and say, "Oh, I have to stop this medication and start this one." They can clarify, "Hey, the note says this, but that's not accurate," or ask, "I need to understand, what did you mean by that?"

A Matter of Trust

Open notes provides a crucial opportunity to ensure the medical record is complete, accurate, and mutually understood. It's not uncommon for a provider to think that they communicated one treatment plan and the patient to hear something else. Every provider has been a patient at some point, and we have all had times where we a) forgot important questions we wanted to ask and b) may not remember what our providers told us.

Open notes also empowers patients and providers to deepen their relationship and their bond of trust. Preserving that trust is especially important now that patients come to visits often having researched their symptoms and possible conditions and treatments. If what you say doesn't match up to what they have seen online, they may have less confidence in you or your clinical abilities.

Trust is at the core of all provider-patient relationships. Ultimately, the success of the treatment plan is not what you as a provider say or recommend – it's what the patient actually decides to do with it based on their trust in you.

Opportunities to Learn

Open notes can also augment patient education. The notes can refer to websites and other materials that patients can review as part of the treatment plan – or even provide homework for patients to do between appointments.

The Defense Health Agency has many resources to help MHS providers learn how to write open notes as well, including this webinar. Three tips you can easily incorporate into writing open notes now are:

1. Put yourself in the role of the patient. What would you want to know about the provider's observations and recommendations, especially in the diagnostic assessment and treatment plan that you would want to read later? What would you want to share with your family and support network?
2. Use plain language without medical or military jargon. Patients are only going to improve as much as they understand the treatment plan – and how are they going to comply with any of it if they can't understand what it says?
3. Include only the information that needs to be there. Be focused and concise, including information that supports the diagnosis and treatment plan and omitting unnecessary personal details.

A Sample Open Note

Let's say you've met with a patient who's having a relationship issue. In your open note about the conversation, don't share the nitty-gritty details of an argument the patient had and who said what to whom.

Instead, you could write something like, "Patient discussed some challenges in their relationship, and we explored various ways of improving communication in that relationship. Patient left with the following tools, which I asked them to practice going forward." If you're a follow-on provider, you can see that the patient had some relationship difficulties and has a treatment plan in place. If you need the specifics, you can ask the patient.

Think of an open note as repeating the high-level takeaways from your meeting, which the patient can review each time they read it. By treating every encounter note as an open note, you can be confident you are following a best practice becoming more widespread every day. Open notes offers the opportunity for you as a provider to demonstrate your commitment to improving outcomes by building patient engagement, one note at a time.